If a doctor gives orders over the phone to admit a patient to observation but does not see the patient till the next day and then decides to discharge the patient, what code would be billed?
In this example, the doctor neither admitted the patient on the actual date of admission nor did a true “admission and discharge” service the same date of service as represented by CPT codes 99234-99236. These codes include an admission, keeping a record of observations/assessments performed by the physician, and discharge. In this example, the doctor made only one evaluative visit and decided to discharge the patient. The provider may bill a code from the series 99218-99220 if his/her documentation meets the code’s descriptor. A discharge visit (99217) should not be billed. See MLN Matters articles # 5793 and 5791 for appropriate coding of other observation status scenarios via the following links: http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5793.pdf http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5791.
In this example, the doctor neither admitted the patient on the actual date of admission nor did a true “admission and discharge” service the same date of service as represented by CPT codes 99234-99236. These codes include an admission, keeping a record of observations/assessments performed by the physician, and discharge. In this example, the doctor made only one evaluative visit and decided to discharge the patient. The provider may bill a code from the series 99218-99220 if his/her documentation meets the code’s descriptor. A discharge visit (99217) should not be billed.
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